Fibromyalgia & Rheumatoid Arthritis Features Overlap

Patients with rheumatoid arthritis who have increased levels of fibromyalgianess (FMness)—a continuous measure of fibromyalgia—show neurobiological features that are consistently observed in fibromyalgia patients, according to a study that used neuroimaging.

“This is the first study to provide neuroimaging evidence that rheumatoid arthritis [RA] is a mixed pain state,” said senior author Daniel Clauw, MD, a professor of anesthesiology and the director of the Chronic Pain and Fatigue Research Center at the University of Michigan, in Ann Arbor.

I believe this is true for me and my EDS + Fibromyalgia: the endlessly repeating small injuries and pains from EDS eventually sensitized my nervous system into a state of “fibromyalgia-ness”. I can easily imagine the same would happen with RA.

“This study suggests that many of the symptoms that RA patients experience are related to the central nervous system [CNS], as opposed to classic peripheral inflammatory mechanisms.”

Dr. Clauw noted that it has been well known for many years that between 20% and 30% of patients with RA or other autoimmune disorders also meet criteria for fibromyalgia.

“This condition was previously called secondary fibromyalgia because the fibromyalgia was thought to be due to the ongoing nociceptive input from RA, which is akin to central sensitization.”

However, all of the imaging studies—including using functional magnetic resonance imaging (fMRI)—for fibromyalgia and other disorders have excluded patients with RA or other autoimmune disorders

Previous research by Dr. Clauw’s group and others suggests that comorbid fibromyalgia in RA patients should be considered as a continuum—the degree to which central factors are augmenting or amplifying what is occurring in the periphery—rather than a definitive yes or no for fibromyalgia.

“We believe that the single most robust finding on fMRI studies in fibromyalgia and other similar centralized pain conditions is increased connectivity between the default mode network and the insula,” Dr. Clauw said.

Hence, we hypothesized that in RA patients, their score on the Fibromyalgia Survey Criteria would be correlated with the strength of the default mode—insula connectivity. And that is exactly what we found.

Left mid/posterior insula was also the only brain region that correlated with the fibromyalgia measure.”

For pain management specialists, if a patient with RA also has fibromyalgia, “then their pain and other symptoms may be better managed by using treatments that work for fibromyalgia, rather than thinking that all of the pain is due to ongoing inflammation that will respond to an increasing number of anti-inflammatory drugs,” Dr. Clauw said.

As one of the few physicians board certified in both rheumatology and pain medicine, Dr. Boomershine said the clinical importance of the current study cannot be overstated.

“Rheumatologists and other specialists who treat inflammatory conditions are under intense pressure to use increasingly more powerful and expensive therapies to induce and maintain disease remission. Unfortunately, though, these specialists often assume pain [from RA] is always due to persistent inflammation and their default treatment is to increase immunosuppression.”

But it is the responsibility of pain specialists to “identify and treat noninflammatory causes of pain in patients with inflammatory conditions to prevent overuse of immunosuppressives that can have serious costs, both monetary and human, for patients,” he said.

The current study demonstrates that fcMRI “may one day provide a means to quantify the contribution of central sensitization to a patient’s pain and inform treatment decisions,” Dr. Boomershine said.

That’s a frightening thought. Once researchers can quantify something that can in reality only be qualified (i.e. described by its quality, like art or teaching), it’s sure to be used to minimize and standardize our pain.

They would find a way to create a “scientific and objective” pain scale from such scans and then categorize only the most severe pain as even deserving of treatment. (which they are actually doing already)

But those of us with chronic pain know how pain increases dramatically with duration, especially the kind of persistent, but vague, deep, aching pain that I cannot escape even lying down. That’s centralized pain, resistant to opioids, but manageable with Lyrica (for me).

I don’t see how those of us with EDS can avoid developing pain centralization from living under the constant assault of our body’s pain signals for years or even decades.

“However, due to the technical expertise and cost required for fcMRI, it will likely be many years before this technique becomes widely available.”

Thank goodness – by then perhaps we’ve learned more about how important individual differences are to our biological functions, perceptions, and feelings.

This study reaffirms the importance of considering and treating the patient as a whole and not just managing their disease.”

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